Deathscapes

Villawood 12b - quote

‘In all three deaths, some of the actions of some staff were careless, ignorant or both, and communications were sadly lacking. SASH procedures were not followed by DIAC or Serco personnel, DIAC failed to ensure that Serco and IHMS were fulfilling the terms of the contract between them and there were startling examples of mismanagement on the part of DIAC, Serco, and IHMS…it is the failure of systems which in my view require remedy.’